The treatment of extremity ballistic injury is challenging in that the zone of injury can be extensive and determining the surgical exposure can be difficult. We describe a method of pre-operative evaluation of the zone of injury in conjunction with the regional anesthesiologist utilizing ultrasound to determine the presence of nerve disruption. This non-invasive method of examination may elucidate whether significant nerve exists and may also serve to pinpoint the location of injury. Such information allows the surgeon to more effectively and efficiently surgically expose the zone of injury and understand the boundaries of the nerve outside the zone of injury. Moreover, such preoperative evaluation may at times obviate the need for exploratory surgery at all. It is important for the anesthesiologist and surgeon to work together with respect to the ability to both interpret the ultrasound images and to clinically correlate the findings. The zone of tissue disruption in ballistic injuries is extremely variable. It is beneficial to both the surgeon and patient to engage in a collaborative effort with an experienced regional anesthesiologist who is well-versed in interpretation of ultrasound images and tissue plane disruption in an effort to minimize surgical time and the potential unintended consequences of unnecessary exploration. We present a series of cases representing instances wherein the zone of injury was small, extensive, and a unique situation in which there was in fact no injury present despite clinical symptoms and MRI consistent with radial nerve disruption.

In 2011 health policy dictated a reduction in iatrogenic infections, such as Clostridium difficile (C. diff), this resulted in local change to antimicrobial policy in orthopaedic surgery. Previous antimicrobial policy was Cefuroxime, this was changed to Flucloxacillin and Gentimicin. Following this change an increased number of patients appeared to suffer from acute kidney injury (AKI). We initially evaluated the incidence of AKI pre and post antibiotic change and found a correlation between the Flucloxacillin and AKI. We then made changes to antibiotic policy to mitigate the increased rates of AKI and proceeded to evaluate the outcomes.

In this prospective study all patients admitted with fracture neck of femurs were identified from the National Hip Fracture database and data obtained. The degree of AKI was classified according to the validated RIFILE criteria.

Evaluation showed a 4 fold decrease, from 13% to only 3%, in AKI after introduction of the modified antibiotic policy. C.difficile continues to be non-existent since this change.

Flucloxacillin obviously had a significant impact on this patient group. However, we have shown that with appropriate changes to antibiotic policy AKI associated morbidity can be significantly reduced. Dose dependent antibiotics will now be given based on weight and eGFR.

In late 2011 there was a change in antimicrobial policy in orthopaedic surgery to reduce the Clostridium difficile (C. diff) rate, this was inducted top down from government, to PCT, to hospital trust. The previous antimicrobial policy was Cefuroxime, this was changed to Flucloxacillin and Gentimicin. Following this change it was noticed an increased number of patients appeared to suffer from acute kidney injury (AKI). This led us to evaluate the incidence of AKI pre and post antibiotic change and look at the causes behind this.

In this retrospective study all patients admitted with fracture neck of femurs were identified from the National Hip Fracture database and data pulled. The degree of AKI was classified according to the validated RIFILE criteria.

Evaluation showed 2–4 fold increase in AKI since antibiotic change. Although mortality was decreased in these patients, the incidence of AKI had increased significantly. However, C. difficile has been obliterated by this change.

The investigation highlights potential problems with increased rates of AKI amongst NOF patients, since antibiotic change. Flucloxacillin may have significant impact on this patient group. Dose dependent antibiotics will now be given based on weight and eGFR. Further analysis of this new change needs to be evaluated.